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• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K45/00—Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
  • A61K45/06—Mixtures of active ingredients without chemical characterisation, e.g. antiphlogistics and cardiaca
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/40—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having five-membered rings with one nitrogen as the only ring hetero atom, e.g. sulpiride, succinimide, tolmetin, buflomedil
  • A61K31/407—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having five-membered rings with one nitrogen as the only ring hetero atom, e.g. sulpiride, succinimide, tolmetin, buflomedil condensed with other heterocyclic ring systems, e.g. ketorolac, physostigmine
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P11/00—Drugs for disorders of the respiratory system
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
  • A61P25/20—Hypnotics; Sedatives

Definitions

• the present invention relates to a method of treating and diagnosing snoring, sleep apnea and other forms of sleep disordered breathing, and to a means for carrying out said method.
• patency of the upper airway A basic requirement for breathing is the patency of the upper airway. This, of course, also holds true for breathing during sleep. It has recently been described that such patency - and thus breathing - may be partially or totally interrupted during sleep due to a collapse or obstruction of the upper airway; it should be observed that obstruction, in the context of the present invention, excludes obstruction by foreign objects or by material excreted by the body, such as mucus. In its simplest form partial upper airway collapse or obstruction is indicated by profound and vigorous snoring. More pronounced collapse or obstruction results in hypopnea, a condition m which airflow is reduced during inspiration with or without concomitant signs of hypoxemia.
• OSA obstructive sleep apnea
• This condition is associated with repeated episodes of interrupted airflow in spite of mspiratory attempts, resulting in hypoxemia, hemodynamic changes and arousal from sleep. Sleep fragmentation, hypoxemia and/or other OSA- associated phenomena yet unidentified are likely to lead to typical daytime symptoms including hypersomnolence, cognitive disturbance, reduced working and driving performance, depression, and loss of memory.
• cardiovascular complications in particular hypertension, cardiac failure, myocardial infarction, and stroke have been associated with OSA. Such symptoms and complications are not confined to severe cases but also observed in cases of partial OSA.
• OSA OSA in the adult male population is in the order of 10-12 o.
• the prevalence of OSA in combination with pronounced daytime symptoms is in the order of 1-3%.
• the prevalence of minor daytime symptoms induced by discrete sleep- related breathing disturbances is unknown.
• habitual snoring is a common phenomenon reported by The pathophysiology of OSA is virtually unknown.
• predisposing factors e.g. obesity, hypertrophied tissue in the upper airway (particularly in children) , and short jaw, there is a large number of OSA-prone individuals lacking these factors.
• OSA The principal forms of treatment in OSA are surgery of the upper airway, mtraoral mandibular advancement devices and long-term treatment with nasal continuous positive airway pressure (nCPAP) . These methods of treatment are cumbersome and expensive.
• Various forms of pharmacological treatment e.g. by administration of t ⁇ cyclic antidepressants, theophyllme, progesterone, have been employed but have not gained wide clinical use.
• One object of present invention thus is to provide a method for the treatment of snoring, sleep apnea and other forms of sleep disordered breathing which reduces and/or eliminates some or all of the drawbacks of the methods known in the art.
• Another object of the present invention is to provide a means for carrying out said method according to the invention.
• a further object of the present invention is its application as a diagnostic tool for detecting the presence of OSA in a patient.
• a method of treating snoring, sleep apnea and other forms of sleep disordered breathing, all of them which included in the term OSA as used herein comprising the administration of a pharmacologically active amount of an agent having an inhibitory effect on acetylcholine esterase, that is, a so-called acetylcholine esterase inhibitor.
• acetylcholine esterase inhibitors will be referred to as choline esterase inhibitors (CEI) in the present application.
• CEI have been used in medicine for the treatment of a number of diseases and abnormal conditions but not for the treatment of snoring, sleep apnea and other form of sleep disordered breathing.
• CEI Choline esterase inhibitors
• Known medical indications in which CEI are or have occasionally been used as medicines include intestinal and bladder atonia and myasthenia gravis.
• CEI of various structure are widely employed as antidotes to clinically used muscle relaxant agents, in particular curare.
• P Taylor, Anticholmesterase Agents in Goodman and Gilman' s The Pharma col ogi cal Basi s of Therapeuti cs, 8th Ed., Pergamon Press, New York etc., 1990.
• the positive effect of CEI in the treatment of OSA-related conditions may be due to the enhancement of cholinergic transmission at the level of the neuromuscular junction or, possibly, in the nervous system, causing increased muscular tone m upper airway muscles during sleep and thereby reducing snoring, sleep apnea and other forms of sleep disordered breathing (OSA) . While this hypothesis provides a scientifically attractive explanation for the observed effect of said
• CEI in the conditions which the present invention seeks to treat it must be emphasized that it must not be considered to be binding in any way on the concept and the working of the present invention.
• Central nervous acetylcholinergic mechanisms are intimately involved in the regulation of wakefulness and sleep, particularly rapid eye movement
• REM sleep Particularly interesting anatomic structures containing cholinergic nerve cells include the dorsal pontine tegmentum, the thalamus, the cerebral cortex and the hippocampus (see Tononi and Pompelano, Pharmacology of the cholinergi c sys tem. In: The Pharmacology of Sleep, Ed. A. Kales, Springer Verlag, Berlin 1995, pp 143-210).
• systemic administration of CEIs can produce an increase in REM sleep and a shortening of the latency from sleep onset to the first episode of REM sleep.
• Infusion of the CEI physostigmine was also shown to reduce sedation and induce arousal in the postoperative phase in patients exposed to major surgical intervention.
• CEI central respiration related mechanisms
• cholinergic activation similar to that seen during natural REM sleep, is associated with a predominant inhibition of upper airway (hypoglossal) activity m animal experimental models.
• Such an effect would advocate an increased tendency to upper airway collapse during sleep and increased acetylcholmergic tone.
• An attractive hypothesis for the observed effect of said CEI may therefore be that the central nervous control of upper airway muscles is profoundly modified in certain disease states such as sleep disordered breathing, a state actually associated with a suppression of the natural progression of sleep, in particular REM sleep and slow wave sleep. Further indirect support for such an interpretation would be that the observed effects were not confined to REM sleep periods but were also seen during non-REM sleep.
• An effective amount of a CEI is one which eliminates or substantially reduces the manifestations of OSA- related conditions over a period of sleep, such as sleep periods from 10 minutes to 10 hours.
• CEI particularly useful in the invention include synstigmine, neostigmine, physostigmine, pyndostigmine, ambenon (ambenonium) , distigmine, demeca ⁇ um, neostigmine, edrophonium, tacrine (9-ammo-l, 2, 3, 4- tetrahydroacridme) , metrifonate, ecothiopate, eptastigmine, tetrahydrobenzazepme and its alkylcarbamate derivatives, amiridme, lmopidine, ENA-713 (a proprietary compound of Sandoz AG in clinical study for the treatment of Alzheimers disease) , velnacnne (a compound in clinical study for the treatment of Alzheimers disease), Cl-INH (a regulatory glucoprotem having CEI activity), thiabendazole, mitezol, 3, 4-
• CEI useful in the invention include a ⁇ sugacin; 5,7-d ⁇ hydro-3- (2- ( 1- (phenylmethyl )-4-p ⁇ per ⁇ dmyl) ethyl )-6H-pyrrolo (3, 2-f) -1,2- benz ⁇ soxazol-6-one; pseudozoanthoxanthin; aminostigmine; atramine; B 156; chinotilm; crotylsa ⁇ n; Cui xing an; Cui xing ning; cycloguamde phenylsulfone; cyclophostin; diethyl mesoxalate; diethyl S-n-propyl phosphorothiolate; diisopropylamme dichloracetate; dnsopropyl- phosphorylthiocholine iodide; dimethylcarbamyl fluoride; d methyl- carbamylcholme; dimethylthionocarbamylcholme; E
• the choline esterase inhibiting effect of the compounds of the invention usually resides in the nitrogen base part of the agent, the expert in the art will recognize that the desired pharmacological effect will be retained as long as the structure of the nitrogen base remains essentially unchanged. It is thus possible to combine various pharmacologically acceptable acids with said active bases to obtain CEI agents having have desirable properties from a pharmaceutical formulation standpoint, such as salts being only slightly soluble in aqueous solutions which may of particular interest in the manufacture of controlled release CEI- preparations.
• the CEI mixture of such inhibitors is advantageously formulated in a way appropriate to the chosen administration route.
• the CEI or mixture of such inhibitors may be administered by various routes.
• the most preferred route is by peroral administration.
• the compound of the invention is incorporated in tablets, lozenges, capsules or similar, in particular solid pharmaceutical preparations designed for preferred uptake of the compound through the oral mucosa.
• Most preferred is absorption within the oral cavity, such as sublingual absorption and, consequently, pharmaceutical compositions adapted to such absorption are of particular interest.
• Knowledge about clinical pharmacokinetics of CEI is useful in designing CEI preparations for administration to a patient.
• CEI are salts of quaternary amines or tertiary amines which may form salts with appropriate organic or inorganic acids.
• CEI (as salts) can be expected to possess physical properties similar to other kinds of pharmacologically active agents of quaternary or tertiary amine type, such as, for example, synthetic anti uscarinic agents (clinidmum salts, hyoscine methobromide, orphenadrine hydro-chloride); information in respect of formulation techniques for such known antimuscarinic agents thus is useful in carrying out the present invention (for references, see: Martmdale, The Clini cal Pharma copeia , 29th Ed., The Pharmaceutical Press, London 1989.
• the nerves supplying the submandibular triangle such as the hypoglossal and the glossopharyngeal nerves
• slow continuous administration of the compound according to the invention in close proximity to these nerves is preferred, such as sublingual administration.
• the CEI will be taken up by the mucosa m the sublingual area and migrate to said nerves to exhibit its choline esterase inhibiting function. It is desirable to design the buccal or sublingual pharmaceutical formulation for sustained release of the choline esterase inhibitor to avoid the need for frequent administration which would be particularly difficult during sleep.
• a suitable solution for this problem would be the fixation, at least for a certain period of time, of the formulation containing the choline esterase inhibitor in or near the sublingual region.
• This could be effected by fixation of a holding means for the tablet, lozenge, or similar to one or several teeth of the lower jaw, or by implantation of a holding means, of titanium, for instance, in the lower aw.
• a holding means could also be used for holding a small plastic or other container enclosing a liquid or solid pharmaceutical composition of the choline esterase inhibitor of the invention, from which container the inhibitor would leak through a minute opening or through a system of micropores driven by, for example, osmotic pressure, such as in the technology for sustained release of drugs developed by Alza Corp.
• the compound of the invention m a polymer matrix, biodegradable or not, from which it would leak slowly into the oral cavity.
• Appropriate technology for producing biodegradable polyester matrices of the polylactide/polyglycolide type for incorporation and sustained release of pharmacologically active compounds is described in, for instance, L A Sanders et al . , J. Pharma ceuti cal Sci . 75 (1986) 356-360, and in U.S. Patent No. 3,773,919 (Boswell) .
• Non-degradable polymers of appropriate physical properties can be also used as matrices .
• Other devices of absorbing material specifically designed for this purpose such as sponges, non-woven inlays, pieces of woven tissue, felt or other absorbent material useful for slow-release purposes of the compounds according to the invention may be placed under the tongue thus restraining their displacement, or may be fixed to a mandibular dental frame in a buccal or frontal position.
• the size and shape of these absorbing devices should be adapted to decrease the risk of displacement and to minimize discomfort. Such adaptation is also necessary to avoid accidental swallowing or aspiration of the device containing the drug. This route of administration ensures a highly localized absorption of the drug by the surrounding tissues affecting the patency of the upper airway a the pharynx during sleep.
• a device of this sort designe ror slow release will extend the potential effect of the drug ovex periods beyond those limited by the basic pharmacokinetic properties of the agent, thereby maximising efficiency and duration of treatment which can be extended to cover the entire sleeping period.
• choline esterase inhibitors may be used in form of their racemates or as substantially pure enantiomers. Parenteral administration of the CEI according to the invention is also feasible.
• the amount of CEI to be administered for treatment of sleep disordered breathing will vary depending on factors such as the particular chemical nature of the inhibitor used, the route of administration, the release profile of the formulation into which it is incorporated, the severity of the disease, individual pharmacokinetic and -dynamic properties as well as the status of the patient.
• the dose range for peroral administration of pyridostigmine will be in the interval from 0.1 to 6,000 mg per 24 hours.
• An amount of from 0.5 to 2,500 mg o£ pyridostigmine is envisaged as the normal range used for peroral administration.
• the appropriate dose range for a particular compound can be determined by titration in routine experiments.
• parenteral, intranasal, and rectal administration is useful, as well as administration by inhalation or transdermal administration, particularly to the skin of the submandibular triangle region.
• the drug formulation When given by peroral administration for gastrointestinal absorption or administered by the parenteral or rectal route the drug formulation is intended to provide a systemic effect.
• Systemic administration offers advantages in cases with reduced local absorption capacity or when a generalised effect involving extended muscle groups of the pharynx and the upper airway is preferred.
• the systemic route of application may be preferable to achieve central nervous effects of the drug, specifically for enhancing the central nervous drive to the upper airway musculature.
• the CEI according to the invention can also be efficiently administered by inhalation, such as by inhalation via the mouth or via the nose.
• the nasal mucosa is easily accessible by use of extra- or intranasal devices, the later ones appropriately shaped and designed similarly to what has been described above for mtraoral or sublingual administration.
• the transdermal route of administration is specifically advantageous in regard of simplicity and from a patient comfort standpoint.
• the agent is applied to the skin in form of a viscous ointment or similar.
• Transdermal systems (patches provided with a liquid or semi-liquid pharmaceutical composition) for controlled drug delivery through the skin are well known in the art, for instance for the administration of nicotine and drugs used for the treatment of diseases of the circulatory system.
• the site of application of transdermal patches can advantageously be a site in the immediate proximity of the upper airway or tongue musculature, such as submentally, on the cheek, the neck, or over the throat.
• the timing of the administration of the composition and/or device comprising a choline esterase inhibiting compound according to the invention will depend on the particular compound, its rate of absorption through the mucosa or the skin, the release profile of the respective sustained release composition and/or device, if used, and similar.
• the administration of the CEI will, in the majority of cases, have to start well in advance of the sleeping period to achieve optimal effect, for instance from 10 minutes to 3 hours prior to the onset of sleep.
• the CEI according to the invention may also be combined, m one and the same pharmaceutical preparation, with other pharmacologically active compounds useful in the treatment of OSA.
• the choline esterase inhibitors according to the invention may also be used for diagnosing sleep disorders related to snoring, sleep apnea or other forms of sleep disordered breathing to dissociate them from other types of sleep disorders .
• the diagnostic method according to the invention comprises administration to the patient a CEI in increasing amounts prior to or during a series of sleep episodes; administration can be in simple or multiple doses.
• the observation of a reduction of the severity and/or number of sleep disordered breathing events or reduced daytime sleepiness/increased alertness is indicative of the presence of obstructive sleep apnea.
• Fig. 1 a preferred but not limiting embodiment illustrated by a single figure (Fig. 1) showing placebo versus physiostigmine effect in each of the patients .
• a double-blind, placebo controlled cross over study with the CEI physostigmine salicylate was undertaken in 10 patients with moderate to severe obstructive sleep apnea (apnea-hypopnea index, AHI 14-94, number n of episodes/hr) .
• Continuous intravenous infusion (12 ⁇ g/mm/kg during 7 hours) of physostigmine salicylate resulted in a mean reduction of AHI of 16.5 (app. 30c) .
• OSA acetylcholine related dysfunction
• CEI have other effects, in particular systemic effects, than those desired in the context of the present invention. These effects are chiefly due to excessive cholinergic stimulation and include increased salivation, nausea and vomiting, abdominal spasms, muscle cramps, bradycardia, increased bronchal secretion, and diarrhoea. It is within the scope of the present invention to counteract a specific side effect of this kind by administration of an agent known in art to be effective in its suppression, for instance an antidiarrhoeal agent, such as loperamide hydrochloride and lidamine hydrochloride, in case of diarrhoea, or an anti-vomiting agents, such as domperidone, m case of nausea and vomiting.
• an antidiarrhoeal agent such as loperamide hydrochloride and lidamine hydrochloride
• an anti-vomiting agents such as domperidone, m case of nausea and vomiting.
• An improved effect of administration of CEI according to the invention can be expected when the medicine is given in combination with an agent capable of counteracting unwanted CEI effects, including an agent for deep sleep promotion, in particular an REM sleep suppressing agent.
• an agent capable of counteracting unwanted CEI effects including an agent for deep sleep promotion, in particular an REM sleep suppressing agent.
• REM sleep suppressing agents include but are not limited to tricyclic antidepressants, selective serotonin reuptake inhibitors, bensodiazepines, cyclopyrrolones, and antihistamines .
• Examples for such agents are amitriptylme hydrochloride or embonate, fluoxetine, lmipramine hydrochloride, mianserin hydrochloride, nortryptiline hydrochloride, paroxetme hydrochloride, phenelzine sulphate, protriptiline hydrochloride, tranylcypromine sulphate, trimipramine maleate, viloxazme hydrochloride, alpraxolam, chlormethiazole edisylate, chlorpromazme hydrochloride, diazepam, droperindol, fluphenazine decanoate, flurazepam hydrochloride, gluthethimide, haloperindol decanoate, lorazepam, meprobamate, nitrazepam, oxazepam, pentobarbitone, pericyazine, pimozide, prochlorperaz e mesylate, quinal
• a pharmaceutical composition containing both of them can be used or they can be administered in separate pharmaceutical compositions simultaneously or consecutively. Consecutive administration is preferred for pharmacokmetic reasons, such as for proper timing of the onset of effect caused by the respective agent. For this purpose sustained or delayed release compositions are preferred.

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